2011 STANDARD Medicare Supplement/ Life Insurance Plans Issued by Forethought Life Insurance Company NORTH DAKOTA MS3000-01-ND
2011 Forethought Standard Medicare Supplement Insurance Plans You can rely on Forethought Standard Medicare Supplement Plans to help pay your Medicare Part A and Medicare Part B charges that Medicare doesn t cover. What s more, you have: Five plans from which to select the coverage that best meets your needs. 30 days to review your Policy; if you re not happy with it, we ll refund your premium. Virtually no claims paperwork to file. The Forethought Standard Medicare Supplement insurance is underwritten by: Forethought Life Insurance Company Administrative office PO Box 14659 Clearwater, FL 33766-4659 Choose the Forethought Standard Medicare Supplement Plan that s right for you. 1
Choose the Forethought plan that best fits your needs! Medicare Part A hospital coverage MEDICARE PAYS PLAN A PAYS PLAN C PAYS PLAN F PAYS PLAN G PAYS PLAN N PAYS Deductible $1,132 $1,132 $1,132 $1,132 First 60 days 100% Coinsurance All but $283 $283 $283 $283 $283 $283 61 90 days a day a day a day a day a day a day Coinsurance All but $566 $566 $566 $566 $566 $566 91 150 days a day a day a day a day a day a day (Lifetime Reserve) Extended hospital coverage (up to an additional Eligible Eligible Eligible Eligible Eligible 365 days expenses expenses expenses expenses expenses in your lifetime) Benefit for blood All but 3 pints 3 pints 3 pints 3 pints 3 pints 3 pints Hospice care All but limited coinsurance for Medicare Medicare Medicare Medicare Medicare outpatient drugs copayment/ copayment/ copayment/ copayment/ copayment/ and inpatient coinsurance coinsurance coinsurance coinsurance coinsurance respite care Skilled nursing facility care First 20 days 100% Coinsurance All but $141.50 Up to $141.50 Up to $141.50 Up to $141.50 Up to $141.50 21 100 days a day a day a day a day a day Medicare Part B physician s services and supplies Deductible $162 $162 Coinsurance Generally 80% Generally 20% Generally 20% Generally 20% Generally 20% Generally 20% Excess benefits 100% up to 100% up to Medicare s limit Medicare s limit Benefit for blood All but 3 pints 3 pints 3 pints 3 pints 3 pints 3 pints Other benefits* Emergency care 80% to 80% to 80% to 80% to received outside lifetime max lifetime max lifetime max lifetime max the USA of $50,000 of $50,000 of $50,000 of $50,000 *Refer to the next page and your Outline of Coverage for more information. Subject to copayment for office and emergency room visits. 2
Your care benefits Medicare Part A hospital coverage The Forethought Standard Medicare Supplement Plan pays the $1,132 Part A (inpatient) deductible for Plans C, F, G and N for each benefit period. First 60 days After the Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semi-private room and board, general nursing and miscellaneous hospital services and supplies. Coinsurance Plans A, C, F, G and N pay $283 a day when you are hospitalized from the 61st day through the 90th day. When you are hospitalized from the 91st day through the 150th day, the Plans pay $566 a day for each Lifetime Reserve day used. Extended hospital coverage If you are in the hospital longer than 150 days during a benefit period and you have exhausted your 60 days of Medicare lifetime reserve, Plans A, C, F, G and N pay the Part A Medicare eligible expenses for hospitalization, paid at the Diagnostic Related Group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for blood Medicare has one calendar year deductible for blood that is the cost of the first three pints. Plans A, C, F, G and N pay the deductible. Skilled nursing facility care Medicare pays all eligible expenses for the first 20 days. Coinsurance Plans C, F, G and N pay up to $141.50 from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare certified skilled nursing facility within 30 days of being hospitalized for at least three days. Medicare Part B physician services and supplies Deductible Plans C and F pay the $162 calendaryear deductible. Coinsurance After the Part B deductible, Plans A, C, F and G generally pay 20% of eligible expenses for physician s services, supplies, physical and speech therapy, and ambulance service. After the Part B deductible, Plan N generally pays 20% of the eligible expenses for physician s services, supplies, physical and speech therapy, and ambulance services except up to a $20 copayment for office visits and up to a $50 copayment for emergency room visits. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then generally 20% of eligible expenses will be paid. Excess benefits Your bill for Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plan F and G will pay 100% up to the charge limitation established by Medicare. Benefit for blood Medicare has one calendar year deductible for blood that is the cost of the first three pints. Plans A, C, F, G and N pay the deductible. Other benefits* Emergency care received outside the U.S. After you pay a calendar-year deductible, Plans C, F, G and N pay you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for medically necessary emergency care. Hospice care benefit Plans A, C, F, G and N pay the copayment/coinsurance amount for all Part A Medicare eligible hospice care and respite care expenses. *Refer to the next page and your Outline of Coverage for more information. 3
Forethought Medicare Supplement Plans A Forethought Standard Medicare Supplement insurance policy helps pay eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges that exceed what Medicare and your Standard Medicare Supplement insurance policy will pay. Medicare Eligible Expenses means expenses covered by Medicare to the extent recognized as reasonable and medically necessary by Medicare. Forethought Standard Medicare Supplement Plans will not pay for: Any expense incurred before your Policy Date Services for which no charge is made Expenses paid by Medicare Hospital or skilled nursing facility confinement charges incurred prior to the effective date of coverage of the policy Loss or expense that is payable under any other Medicare Supplement insurance policy or certificate Medicare Part A Eligible Expenses for hospital/skilled nursing facility care include expenses for semi-private room and board, general nursing and miscellaneous services and supplies. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 consecutive days. Medicare Part B Eligible Expenses for medical services include expenses for physician s services, hospital outpatient services and supplies, physical and speech therapy, and ambulance service. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by Standard Medicare Supplement Plans. Benefits are paid to you, your hospital or doctor. You have 31 days from your renewal date to pay your premium. Your policy will stay inforce during this 31-day grace period. Your Policy is guaranteed renewable. Your policy cannot be canceled. It will be renewed as long as the premiums are paid on time and the information on your application is correct. You cannot be singled out for a rate increase no matter how many times you receive benefits. Your premium changes only (a) each year on the renewal date coinciding with or following the anniversary of your Policy Date until you reach age 99; and (b) when the same premium change is made on all inforce Forethought Standard Medicare Supplement policies of the same form issued to persons of your classification in the same geographic area of your state. This is a brief description of your coverage. This brochure must be accompanied by the Outline of Coverage. For a complete description of benefits, exceptions and limitations, please read your Outline of Coverage and your Policy. Not connected with or endorsed by the United States government or the federal Medicare program. This is a solicitation of insurance and an agent will contact you by telephone. *Refer to the next page and your Outline of Coverage for more information. 4
Agent checklist for completing the Medicare Supplement Application This packet contains the following forms needed to complete an Application For Medicare Supplement Insurance. Please tear out the application and all pages marked RETURN TO COMPANY and leave the remaining pages with the applicant(s). Please review the following information carefully and complete all needed forms: Application For Medicare Supplement Insurance (Form MSAP1000-01 or MSAPC1000-01) Medicare Supplement If the applicant(s) is applying during Open Enrollment or a Guaranteed Issue period, Section 4 is not required to be completed Section 5 should be completed only if the applicant(s) would like his/her payments to be deducted automatically from his/her checking/savings account. This option applies only if premiums are paid monthly Agent Certification (Form AGTCRT10-01) This form must be signed by the agent and by the applicant(s). Calculate your premium This form is used in coordination with the Outline of Coverage, to calculate the correct (Medicare Supplement premium). This form must be returned with the application. Fax Transmittal Follow the instructions on this form only if the applicant(s) elects to pay premiums using ACH and you are submitting the underwriting documents via fax instead of regular mail. Authorization to Release Confidential Medical Information (Form MS-HIPAA10-01) Must be completed only if applying outside Open Enrollment or a Guaranteed Issue period for Medicare Supplement. If both spouses are applying for coverage on the same application, then both must sign the form. Notice to Applicant regarding replacement of Medicare Supplement insurance or Medicare Advantage (Form MS-RN10-01) This form must be completed if replacement of an existing Medicare Supplement policy is involved. One signed copy must be returned to the Administrative Office and the other signed copy must be left with the applicant(s). Investigative Consumer Report Notice to Applicant, Medical Information Bureau Disclosure Notice and Medicare Supplement/Select Initial Premium Receipt (MSREC-01) The Initial/Premium Receipt must be left with the applicant(s) and the full modal premium is required with all applications. Please note, you are also required to provide the applicant(s) with the following items: Guide to Health Insurance for People with Medicare Outline of Coverage (Form MSOC10-01) Premiums and policy fee Utilize the Outline of Coverage to determine Medicare Supplement premiums. Determine ZIP code where the client resides and find the correct rate page for that ZIP code Determine Plan Determine if tobacco or non-tobacco use Find age/gender Verify that the age and date of birth are the exact age as of the application date, this will be your base monthly premium Use the Calculate your premium form to adjust the monthly premium for different modes and to add the policy fee A voided check needs to be submitted with the Application for EFT There will be a one-time Medicare Supplement application fee of $25.00 that must be collected with each applicant s initial payment. If both spouses are written on the same application, $50.00 in fees must be collected. This will not affect the renewal premiums. Mailing Address Forethought Life Insurance Company Administrative office P.O. Box 14659 Clearwater, FL 33766-4659 FAX Number for New Business - EFT Applications 1-800-497-6115 Overnight/Express Address Forethought Life Insurance Company Administrative office 2536 Countryside Boulevard, Suite 501 Clearwater, FL 33763 MS4000-01-ND 2010 Forethought 0810
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Agent Certification FORETHOUGHT LIFE INSURANCE COMPANY Administrative Office P.O. Box 14659, Clearwater, FL 33766-4659 1-877-492-5870 I the undersigned insurance agent certify; THAT, I have taken an application for: Primary insured: Applicant B: Medicare Supplement Medicare Supplement Medicare Supplement Medicare Supplement Standard Select Standard Select Plan A Plan C Plan A Plan C Plan C Plan F Plan C Plan F Plan F Plan G Plan F Plan G Plan G Plan N Plan G Plan N Plan N Plan N Offered by FORETHOUGHT LIFE INSURANCE COMPANY, to (Applicant(s)), THAT, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions and limitations of the plan. THAT, I am a licensed agent of this insurance company and have given a company receipt for an initial premium in the amount of $ which has been paid to me by Check Money order ACH (Check appropriate method of payment) THAT, I have clearly explained any benefits of this plan are a supplement to any benefits that the applicant may be entitled to receive from the Medicare Program of the Federal Government. THAT, I have not made any representation to the applicant that there is any endorsement whatsoever by the Social Security Administration or the Centers for Medicare and Medicaid Services in connection with this insurance policy being applied for. Date Signature of agent I, the undersigned applicant, understand that I will receive a copy of this form when my policy is issued and delivered to me. Name of agency Signature of applicant Address of agent / Agency Signature of spouse, if applying Phone number AGTCRT10-01 RETURN TO COMPANY 2010 Forethought 0810
Calculate your premium Forethought Medicare Supplement Medicare Supplement Plan Before you begin: If you re not in your open enrollment or guarantee issue period, please see chart below to determine your eligibility for coverage. Steps Premium Write in your Medicare Supplement Plan s premium from the Outline of Coverage table. Payment Options To determine other payment schedules, multiply your monthly premium by: 3 to pay four times a year (quarterly) 6 to pay twice a year (semi-annually) 12 to pay once a year (annually) Enrollment/Policy fee There is a one-time application fee of $25.00 This will be collected with your initial payment and will NOT affect your renewal premium. Example Rate displayed is used for calculation purposes only. $128.52 Applicant s premium Decline Standard Decline $128.52 Monthly payment Height Weight Weight Weight $385.56 Quarterly payment $771.12 Semi-annual payment $1,542.24 Annual payment $128.52 + $25.00 = $153.52 Example shows initial payment (monthly schedule). Height and weight chart To determine whether you may purchase coverage, locate your height, then weight in the chart below. If your weight is not in the Standard column, we re sorry, you re not eligible for coverage at this time. If your weight is located in the Standard column, you may proceed in completing the application. FORETHOUGHT MEDICARE SUPPLEMENT Decline Standard Decline Height Weight Weight Weight 4 2 < 54 54 145 146 + 4 3 < 56 56 151 152 + 4 4 < 58 58 157 158 + 4 5 < 60 60 163 164 + 4 6 < 63 63 170 171 + 4 7 < 65 65 176 177 + 4 8 < 67 67 182 183 + 4 9 < 70 70 189 190 + 4 10 < 72 72 196 197 + 4 11 < 75 75 202 203 + 5 0 < 77 77 209 210 + 5 1 < 80 80 216 217 + 5 2 < 83 83 224 225 + 5 3 < 85 85 231 232 + 5 4 < 88 88 238 239 + 5 5 < 91 91 246 247 + 5 6 < 93 93 254 255 + 5 7 < 96 96 261 262 + 5 8 < 99 99 269 270 + Decline Standard Decline Decline Standard Decline Height Weight Weight Weight 5 9 < 102 102 277 278 + 5 10 < 105 105 285 286 + 5 11 < 108 108 293 294 + 6 0 < 111 111 302 303 + 6 1 < 114 114 310 311 + 6 2 < 117 117 319 320 + 6 3 < 121 121 328 329 + 6 4 < 124 124 336 337 + 6 5 < 127 127 345 346 + 6 6 < 130 130 354 355 + 6 7 < 134 134 363 364 + 6 8 < 137 137 373 374 + 6 9 < 140 140 382 383 + 6 10 < 144 144 392 393 + 6 11 < 147 147 401 402 + 7 0 < 151 151 411 412 + 7 1 < 155 155 421 422 + 7 2 < 158 158 431 432 + 7 3 < 162 162 441 442 + 7 4 < 166 166 451 452 + Applicant B s premium MS4001-01 COMPLETE AND RETURN WITH APPLICATION 2010 Forethought 0810
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Forethought Life Insurance Company MSCFAX01-01 2010 Forethought 0910
Forethought Life Insurance Company MSCFAX01-01 2010 Forethought 0910
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Forethought Life Insurance Company ( Forethought ), provides innovative insurance and financial solutions for families managing retirement and end-of-life needs. Headquartered in Indianapolis, Indiana, Forethought provides life insurance and annuities. Forethought has been consistently recognized by A.M. Best for financial strength. As of June 30, 2010, Forethought has assets owned and under management in excess of $4.7 billion, approximately $1.1 billion in annual revenue, more than $4.9 billion of life insurance and annuity business in force, and has served more than 2 million policyholders since 1985. Forethought Life Insurance Company Administrative office PO Box 14659 Clearwater, FL 33766-4659 Phone: 1-877-492-5870 www.forethought.com MS3000-01-ND 2011 Forethought 0311